PNHP

Denied Medical Claims Most Likely with Private Insurance & Rarely Resolved

Denied Medical Claims Most Likely with Private Insurance & Rarely Resolved

Summary: This national survey finds that 21% of privately insured individuals had claims denied in the last year, on top of a similar frequency of denied or delayed prior authorizations. Those with other insurance problems (like high drug copays) had more denials, suggesting flawed insurance. Just 29% of denials were resolved.

Consumer Survey Highlights Problems with Denied Health Insurance Claims, KFF, Sept. 29, 2023, by Karen Pollitz, et al

An earlier KFF survey of adults with health insurance found that roughly 6 in 10 insured adults experience problems when they use their insurance. Problems studied include denied claims, network adequacy issues, preauthorization delays and denials, and others. … This Data Note takes a closer look at insured adults who said that in the past year, insurance did not pay for care that they received and thought was covered: a “denied claim.”

Comment:

By Jim Kahn, M.D., M.P.H.

This important analysis documents the extent and shape of claims denials. Here are the key points:

Figure 1: Almost 1 in 5 insured adults had at least one claim denied in the last year. Those with private insurance had more denials.

Figure 4: Individuals with other insurance problems – like the 16% with prior authorization denials or delays, or the 23% with drug payment issues, or the 27% with low insurance payments – were far more likely (as high as 76%) to experience claims denials. This suggests that some insurance is failing way short on multiple measures of financial protection.

Figure 5: Only 29% of those with denied claims had their major insurance problem resolved. As the full report indicates, many people don’t understand the denial rules or how to appeal.

If you want further insights, read the full report.

It’s no wonder that 40% of Americans have significant medical debt with the combined high prevalence of claims denials, prior authorization denials, and high cost-sharing.

Needless to say (but I do like to say it), single payer would greatly simplify and largely eliminate these problems.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Hospitals are dropping Medicare Advantage left and right

By Jakob Emerson
Becker’s Hospital Review, September 27, 2023

Medicare Advantage provides health coverage to more than half of the nation’s seniors, but a growing number of hospitals and health systems nationwide are pushing back and dropping the private plans altogether.

Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.”

In late September, Scripps began notifying patients that it is terminating Medicare Advantage contracts for its integrated medical groups, a move that will affect more than 30,000 seniors in the region. The medical groups, Scripps Clinic and Scripps Coastal, employ more than 1,000 physicians, including advanced practitioners.

Mr. Van Gorder said the health system is facing a loss of $75 million this year on the MA contracts, which will end Dec. 31 for patients covered by UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Centene’s Health Net and a few more smaller carriers. The system will remain in network for about 13,000 MA enrollees who receive care through Scripps’ individual physician associations.

“If other organizations are experiencing what we are, it’s going to be a short period of time before they start floundering or they get out of Medicare Advantage,” he said. “I think we will see this trend continue and accelerate unless something changes.”

Bend, Ore.-based St. Charles Health System has taken it a step further and is not only considering dropping all Medicare Advantage plans, but is also encouraging its older patients not to enroll in the private Medicare plans during the upcoming enrollment period in October.

The health system’s president and CEO, CFO and chief clinical officer cited high rates of denials, longer hospital stays and overall administrative burden for clinicians.

“We recognize changing insurance options may create a temporary burden for Central Oregonians who are currently on a Medicare Advantage plan, but we ultimately believe it is the right move for patients and for our health system to be sustainable into the future to encourage patients to move away from Medicare Advantage plans as they currently exist,” St. Charles Health CFO Matt Swafford said.

“I feel terrible for the patients in this situation; it’s the last thing we wanted to do, but it’s just not sustainable with these kinds of losses,” Mr. Van Gorder added. “Patients need to be aware of how this system works. Traditional Medicare is not an issue. With these other models, seniors need to be wary and savvy buyers.”

Here are seven more recent examples of hospitals dropping Medicare Advantage contracts:

1. Adena Regional Medical Center is terminating its contract with Anthem BCBS’ Medicare Advantage and managed Medicaid plans in Ohio, effective Nov. 2. The flagship facility of Chillicothe, Ohio-based Adena Health System said rate negotiations between the organizations “have not been productive,” leading it to terminate its agreement with Anthem, whose parent company is Elevance Health.

2. Since Aug. 1, 11,000 Anthem Medicare Advantage members in Virginia have not had access to Cincinnati-based Bon Secours Mercy facilities. Anthem’s Medicare Advantage members in Ohio and Kentucky will be out of network with a majority of Bon Secours facilities as of Oct. 1.

3. Corvallis, Ore.-based Samaritan Health Services ended its commercial and Medicare Advantage contracts with UnitedHealthcare. The five-hospital, nonprofit health system cited slow “processing of requests and claims” that have made it difficult to provide appropriate care to UnitedHealth’s members, which will be out of network with Samaritan’s hospitals on Jan. 9. Samaritan’s physicians and provider services will be out of network on Nov. 1, 2024.

4. Cameron (Mo.) Regional Medical Center stopped accepting Cigna’s MA plans in 2023 and plans to drop Aetna and Humana in 2024. It plans to continue Medicare Advantage contracts with UnitedHealthcare and BCBS, the St. Joseph News-Press reported in May. Cameron Regional CEO Joe Abrutz previously told the newspaper the decision stemmed from delayed reimbursements.

5. Stillwater (Okla.) Medical Center ended all in-network contracts with Medicare Advantage plans amid financial challenges at the 117-bed hospital. Humana and BCBS of Oklahoma were notified that their MA members would no longer receive in-network coverage after Jan. 1, 2023. The hospital said it made the decision after facing rising operating costs and a 22 percent prior authorization denial rate for Medicare Advantage plans, compared to a 1 percent denial rate for traditional Medicare.

6. Brookings (S.D.) Health System will no longer be in network with any Medicare Advantage plans in 2024, the Brookings Register reported. The 49-bed, municipally owned hospital said the decision was made to protect the financial sustainability of the organization.

7. Louisville, Ky.-based Baptist Health Medical Group went out of network with Humana’s Medicare Advantage and commercial plans on Sept. 22, Fox affiliate WDRB reported.

https://www.beckershospitalreview.com…

Health Reform Essentials in Entertaining 2-Minute Videos

Summary: Dr. Glaucomflecken and John Stewart offer a master class on how to concisely convey what’s wrong with US health insurance and why. A dozen 2-minute videos.

Dr. Glaucomflecken, 30 Days of US Healthcare, September 2023, videos (2 min each)

Job Benefits

Deductibles
Co-insurance
Surprise Billing
Pharmacy Benefit Managers
Insurance Kickbacks [to PBMs]
DIR Fees [PBM fees on pharmacies]
Out of Pocket Maximum

Hospital Price Transparency
Payment Processing Fees
Family Medicine Negotiates with UHC

And … An American Gets Health Care Abroad [2022]

Medicare and Corporate Lobbyists in Congress [600 lobbyists: no drug price negotiations part D], The Problem With Jon Stewart, August 30, 2023

Comment:

By Jim Kahn, M.D., M.P.H.

Health policy discussion is often laden with technical jargon. Dr. Glaucomflecken’s amusing skits (in which he plays all roles), and John Stewart’s interviews provide an excellent antidote – they distill fundamentals into biting 2-minute snippets.

Here’s a quick tour of the story they tell, progressing through the videos …

1) Problems with current insurance.

The health insurance “job benefit” actually lowers salary (the worker is paying!). The insurance seems barely worth it … First comes the deductible … thousands of dollars before coverage kicks in. Followed by co-insurance and surprise billing (incompletely resolved with recent legislation, eg ambulances omitted). Pharmacy benefit managers (owned by insurers) manipulate the drug formulary and payment process to extract profits, including dropping generic drugs in favor of brand name (and overcharging for generics). Finally, you hit the out-of-pocket maximum – but beware non-network and excluded services. No wonder medical debt is sky high.

Hospital price transparency is a farce: ignored and incomprehensible for consumers. Electronic billing (efficient, right?) is an excuse to impose a 5% processing fee on providers.

And, the insurers are buying up the doctors.

2) There’s a better way abroad.

In all other wealthy nations, everyone is covered with little or no cost-sharing. Pick your phrase: not rocket science, known technology, best practices.

3) Why, then?

Because, as Stewart says, health industry lobbyists and the donors who hire them control Congress. See the PBM video too – if you earn enough money, you make the laws. Is the Inflation Reduction Act, which the drug companies so hate, a harbinger of real reform?

It’s time for the people to dismantle the fragmented and dysfunctional system in favor of a simple approach that works for patients – single payer.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

California Says No to Privatizing Medicare

By Patty Harvey
North Coast Journal (Humboldt County, Calif.), September 21, 2023

On Sept. 7 an unheralded piece of legislation passed 30-6 to put California unequivocally on the side of protecting traditional Medicare.

Assembly Joint Resolution 4 requests President Biden to eliminate Wall Street profiteering from Medicare via a new program, ACO REACH. REACH is an invention by the Center for Medicare and Medicaid Innovation (CMMI) that began this year without any Congressional approval or oversight. Ending this program will not only be a boon to California with its 6.6 million seniors and people with disabilities but to an entire nation that has enjoyed 58 years of traditional Medicare — the public program we all pay into with our taxes.

The acronym ACO REACH (which stands for Accountable Care Organization Realizing Equity and Community Outreach) sounds pleasant but is wholly misleading. It has opened the floodgates to Wall Street plundering by private equity firms, investment bankers and venture capitalists.

Fifty-eight years ago, the idea of Medicare was to remove all cost sharing and provide unencumbered access to health care for seniors and disabled persons. But from the 1970s forward, a healthcare revisionist history has unrolled in pushback against Lyndon Baines Johnson’s successful implementation of the Medicare program.

In 1972, the Nixon administration allowed the insertion of certain middlemen, (Health Maintenance Organizations (or HMOs), into the Medicare payment process. These middlemen, mostly insurance companies, demand profit but have never produced data to indicate they are delivering on promises of lower costs or improved care. In fact, the data indicates just the opposite.

Medicare Advantage (MA), a privatized version of real Medicare, began in 2003 under the Bush Administration and furthers investors’ goals. It allows non-medical middlemen to restrict provider networks, deny medically prescribed care, cherry pick the healthiest enrollees, lemon drop the sickest and up-code health scores to make patients appear sicker in order to game the Medicare Trust Fund. Medicare Advantage plans overcharge Medicare by more than $75 billion per year, and private equity companies reap many billions more.

It comes down to a payment model called capitation. While Medicare pays providers for services actually performed, Medicare Advantage collects a per-person monthly stipend from the Medicare Trust Fund in anticipation of expected — not actual — need. It’s easy to see how making patients appear sicker would jack up that anticipated need and, accordingly, the capitated payment — without oversight to record whether or not that need is addressed.

The REACH payment model creates similar, dangerous incentives to restrict care. Already 2.1 million Americans have been enrolled in ACO REACH without their express knowledge or consent. Here’s how it works: An investor buys into control over hospital and physician groups and all seniors therein are automatically “aligned” into the REACH program. The only way to opt out is to find a new doctor who is not party to the scheme — not an easy proposition in rural areas where physician populations are shrinking.

An important difference between Medicare Advantage and ACO REACH, however, has to do with that powerful profit incentive. REACH physicians become financial risk bearers, meaning they are incentivized to restrict care in order to gain financially — a proposition that undermines doctor-patient trust. More troubling, while Medicare Advantage programs are required to spend 85 percent of monies received from Medicare on patient health, leaving them to keep 15 percent for overhead and profit, ACO REACH programs may keep up to 40 percent of their take while spending only 60 percent on patient care. Compare that to the 2-percent overhead spent by traditional, nonprofit Medicare.

No wonder people are saying Medicare is going broke! Today, as the Health Justice Monitor has observed, “the system has become maddeningly complex, with armies of functionaries working every angle, straddling every ethical line, to unlock a big safe full of money.”

This ongoing privatization has created a $350-billion market that Wall Street and private equity firms are rushing to exploit, undermining Medicare’s solvency and putting crucial decisions about patient care in the hands of private insurers rather than doctors. Further, the Center for Medicare and Medicaid Services has declared its goal for total privatization of Medicare by the year 2030. If this is allowed to happen, Medicare as we have known it will cease to exist as premiums rise and healthcare access is further delayed and denied.

California’s passage of Assembly Joint Resolution 4 is an important step to put the entire nation on alert to this eventuality. The next step will be improving and expanding Medicare into a universal, single-payer, publicly financed healthcare system similar to those in so many other developed nations that value health as a human right available to all.

Please contact your California state senator today and thank them for this final vote (Go to fastdemocracy.com/bill-search/ca/2023-2024/bills/CAB00030603/ to see sponsors). Humboldt’s own California Second District Sen. Mike McGuire is a co-author of the resolution. His office can be reached at (916) 651-4002.

Patty Harvey (she/her) is a co-chair of Health Care for All/Physicians for a National Health Program-Humboldt and a retired professor at College of the Redwoods.

https://www.northcoastjournal.com…

Understanding & Fighting Investor Ownership of Health Care

Summary: Private for-profit ownership of health care is undermining the health care mission, diverting care resources to shareholder bank accounts. Single payer financing is not enough … we need to resist the corporate takeover. Two important webinars are coming up NEXT WEEK. Listen in, and get involved.

Medicare for All Is Not Enough, The Nation, March 31, 2022, by David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, and John Geyman; covered in HJM here

Dr. Glaucomflecken videos (2 min each):

Comment:

By Don McCanne, M.D.

Single payer financing meets the goal of insuring everyone, funded equitably through progressive taxation. However, it is incapable of controlling the dictates of private ownership with a primary mission of increasing private wealth as opposed to providing the public service of health care for all. Private equity is acquiring not only facilities but also the health care professional groups staffing these facilities. Our article in The Nation summarizes these terrible trends, and Dr. Glaucomflecken distills the problems with his astringent humor. The public service model of single payer cannot work in a system designed to pump up the coffers of billionaires.

Two zoom webinars NEXT WEEK address the hazards of private ownership in health care:

1) The Lancet Webinars: Public policy and health in the USA miniseries: should investors own healthcare?

Tuesday September 26, 2023 2 pm EDT / 11 am PDT
Register here

Four US experts will examine the implications of growing investor ownership of physicians’ practices, hospitals, and other health services in the US, and their consolidation into giant corporate enterprises that dominate insurance and care delivery in many regions of the US. Panelists are luminaries Don Berwick, Rosemary Batt, Steffie Woolhandler, and Claudia Fegan.

2) Health Affairs:  Briefing: How the Ownership and Structure of Health Care Entities Affect Clinicians & Patients

Wednesday September 27, 2023 2 pm EDT / 11 am PDT
Register here

WATCH THE ZOOM MEETINGS AND THEN WORK TOGETHER TO FIGHT THIS PROCESS. WE HAVE TO DO IT. SINGLE PAYER WILL GO NOWHERE IF WE DO NOT ADDRESS THE OWNERSHIP HARM CAUSED BY THE BILLIONAIRES. WE HAVE TO REBUILD THE SYSTEM!

In solidarity and with love,

Don

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medical debt is one of many ills single-payer health care would heal, proponents tell County Council committee

By Bob Batz Jr.
Pittsburgh Union Progress, September 19, 2023

On Monday night in the Gold Room of the Allegheny County Courthouse, Downtown, County Council’s Health and Human Services Committee hosted a public hearing on the growing national and local problem of medical debt. Participants cited piles of statistics, such as how many American adults — 4 in 10 — are saddled with health care debt. Half are unable to pay an unexpected $500 medical bill. One third say that because they can’t afford it, they or family members have skipped medical or dental care.

But it was the human stories that most moved committee chairman Paul Klein, who represents District 11, and six other councilors who were present (two more joined by phone) and others among the two dozen attendees, including two County Council candidates — Carl Redwood and Sam Schmidt — and Pittsburgh City Councilor Barb Warwick.

Dr. Anthony Fiorillo, who is affiliated with Physicians for a National Health Program, told of a friend who lost his job and so lost health insurance for himself and his family. Knowing any diagnosis and treatment could cost tens of thousands of dollars, he put off treatment for worsening chest pains and wound up dropping dead standing at a sporting goods store checkout with his teenage son. He was 51. “I tell you this story to honor him.”

Another physician, Katherine Neely, told of a patient of hers who had a mail-in test clue that he might have colon cancer, but he was only covered if he had a full colonoscopy, which he decided to not pay for himself. He wound up dying. “That’s what medical debt does to citizens of Allegheny County.”

Now working for a private company that provides emergency care, Neely said she sees people seeking medical care who are blocked at the front desk by outstanding balances and copayments who turn around and walk out. “I have no idea if they’re able to get care somewhere else.”

Speakers repeated each other in citing this country as being the richest and spending more than others on health care, yet having some of the poorest outcomes, notably in maternal and infant mortality. That $4 trillion a year, proponents said, could more than pay for much better health care for everyone, from birth to grave.

“We are spending twice as much per capita as every other industrialized country, yet we trail in outcomes,” said Judith Albert, M.D., a retired obstetrician/gynecologist, co-founder of Physicians for a National Health Program of Western PA and steering committee member of the Western PA Coalition for Single Payer Healthcare.

Her fellow invited speaker Ed Grystar, chair of that coalition and a labor activist, said that what they are asking County Council to do is put a referendum on the ballot for citizens to vote for calling on their congressional leaders to push for national single-payer health care. That has happened recently in other states such as Wisconsin and Illinois.

“People are ready for fundamental change,” he said.

Among stats he cited: In the first six months of 2023, the seven big for-profit insurance companies made $40 billion in profits.

A referendum is different than council’s past resolutions, he said — “one tool to push the issue forward.” In addition, he urged the local leaders to do some research to know the numbers and demographics of county residents — insured, underinsured, uninsured — who have medical debt.

Councilor Liv Bennett of District 13 told everyone that it’s not just the indigent and the homeless, as she’s struggling with medical debt and with getting health care coverage at a new day job. “There is a face to these stories.”

Councilor at Large Bethany Hallam said, “I have lots of medical debt,” and she had questions for speakers who talked about negotiating medical bills down for those who couldn’t pay them.

Invited speaker Claire M. Cohen, M.D., a local child psychiatrist and coalition steering committee member who’s also part of PNHP of Western PA, had mentioned doing that for one of the bills for her adult children that she had to pay.

The hospital where this family member is employed sent her to the emergency room there and billed her for more than Cohen thought the procedure costs. So she negotiated the charge from $4,000 down to $2,000 down to $1,000.

Insurance reps tell her she’s “impassioned,” but she said, “I just get mad.”

Earlier Monday, she said, she spent an hour arguing for a patient who was being cut off from a medication that has kept him stable for five years — the kind of cutoffs she’s seeing more lately. “I just think it’s so wrong and so immoral.”

If the U.S. had a Medicare-for-all system, she said, there would be no need for medical debt relief. “People just get good care when it’s needed at a much lower price.”

Klein from the start acknowledged that the county has no legal authority when it comes to national health care, but at Hallam’s urging, Grystar and other speakers offered tangible acts that could help move the needle, such as urging local nonprofit but hugely valued health care providers to donate meds to county residents. Or COVID-19 tests and testing, as is happening in Philadelphia, to keep transmission and bigger problems in check.

On problem pointed out by Schmidt and others is how many health care workers themselves — 51% of the lowest-paid workers at local health care giant UPMC, she said — owe medical debt to their employers. Such workers shouldn’t have to choose between medical care or food, she said.

In his three-minute slot, Redwood said, “I think it is important that we become activist Allegheny County, activist Pittsburgh.”

Warwick noted City Council passage of her colleague Bobby’s Wilson’s bill to buy up $1 million dollars’ worth of city residents’ medical debt for pennies on the dollar and told her county counterparts, “Hopefully we can work together at tackling this problem.”

Klein closed by telling attendees, “We certainly will take this to heart.”

The meeting was livestreamed and a recording is posted online.

https://unionprogress.com…

Kudos to Maine Medical Association’s call for reform

The health policy statement – in favor of universal care – shows that the group recognizes the need to put patients’ and caregivers’ interests first.

By Philip Caper, M.D.
Portland (Maine) Press Herald, September 17, 2023

The Maine Medical Association is to be commended for its newly developed health policy statement, unveiled recently at its annual meeting in Portland (“Maine Medical Association says U.S. health care system needs an overhaul,” Sept. 13). It is the most detailed and comprehensive health policy statement issued by any state medical society in the U.S. It recommended fundamental reform of our existing complicated, fragmented and balkanized system by replacing it with a new comprehensive, simplified and adequately funded national or statewide system, covering all Mainers.

The MMA statement is the product of a nearly two-year effort by a 20-member ad hoc committee. It has been vetted by the MMA Board of Directors and is strongly supported by the recent meeting of the general membership of the association.

I understand that not all of my fellow members of the MMA are enthusiastic about this statement and its proposal for a major overhaul of the health care system – fearing it could disrupt their current business models. But that’s really the whole point of reform. They need to adapt their business model to the needs of patients and caregivers.

Sometimes, fundamental change is necessary to serve the public interest. Such change may require disruption and adaptation. In such times, we must follow our oath as physicians to “put the patient first” and “first do no harm” (including economic harm) ahead of all other considerations. That is the best way to continue to earn the high level of status and public trust we enjoy as physicians.

Medicare for all is the best way to achieve those goals.

https://pressherald.com…

Medicare for All Explained Podcast: Episode 103

Why Medicare for All Is Better Than Direct Contracting

September 15, 2023

Podcast host Joe Sparks considers “direct contracting” agreements (e.g. direct primary care) and finds them preferable to commercial insurance plans in some ways, but a poor substitute for single-payer Medicare for All.

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

US Health Care Is Pretty Good … If You Own an Insurance Company

Summary: Jon Stewart nails it in a vivid one-minute video: Our government-funded health care benefits private for-profit corporations, especially insurers, at our expense.

America’s F*cked Up Tax System, The Problem With Jon Stewart, August 29, 2023, Video (1 min)

Here’s how the system works. You pay taxes to the government, the government pools that money and uses it to provide the people with essential goods and services that they need.

In this country, we’ve got a different system for getting the things we need.

Take health care. We pay taxes to the government and the government gives our money to a middleman: for-profit insurance companies or for-profit health providers. And the insurance companies provide health coverage in exchange for maybe some more money for us and a deductible, that covers not everything certainly not your teeth or your skin or your eyes. It’s a pretty good system if you own an insurance company. Companies like UnitedHealth and Aetna collect 70% of their health plan revenue from government programs. Humana – 90%. These health plan businesses would not exist without our tax money. And it’s not just health care. It’s pharma. …

Comment:

By Jim Kahn, M.D., M.P.H.

What a pleasure to have this talented comedian-social commentator-activist on our side. Jon Stewart is a hero of mine.

The irresistible implication? We need single payer, government-financed and government-paid universal health insurance. Without profit extraction by private sector intermediaries. It’s systematized grift, and we need to end it.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Maine Medical Association says American healthcare system needs an overhaul

The 4,000-member Maine Medical Association is the fifth state medical association to pass a resolution calling for universal healthcare insurance coverage.

By Emily Bader
The Maine Monitor, September 11, 2023

Members of the Maine Medical Association over the weekend strongly endorsed a policy statement calling for universal healthcare insurance coverage, becoming only the fifth state medical association to do so, according to advocacy groups.

“I don’t think it’s credible for physicians to stand on the sidelines of this issue of universal access to care … while millions of patients and thousands in Maine don’t have ongoing primary care, access to specialist care, access to hospital care treatment for severe illness without taking on the risk of bankruptcy or not being — simply not being able to afford it,” Dr. Erik Steele, immediate past president of the MMA, said Monday.

“And many of our members, including me, felt we could not stand on the sidelines of that issue without tackling our position on health system reform,” he said.

Founded in 1853, the MMA is a professional and lobbying organization representing approximately 4,000 medical doctors, osteopathic doctors, medical students and retired physicians across the state.

In June, the MMA board approved the statement and members who attended the association’s annual session in Portland voted to endorse it on Saturday, Steele, a Yarmouth family practitioner, said.

The statement calls for immediate action to “create a system that provides access to healthcare for all (as a public good), contains costs, eliminates health disparities, and ensures a robust public health system.”

“A new system must be a full reconfiguration of health care delivery and financing, designed by evaluating the failures and successes of our present models and the systems of other countries,” the statement read.

Universal insurance coverage should be provided either through an “adequately funded single-payer system or a combination of private and public financing where the federal government has, at minimum, regulatory powers over health care delivery to protect consumers and providers from private profit-driven motives.”

An ad hoc committee formed in 2021 surveyed MMA membership and held four listening sessions across the state before finalizing the statement this spring, committee chair and Augusta ophthalmologist Dr. Maroulla Gleaton said.

The way the current system works, where insurance and costs of drugs stand in the way of patient-provider relationships, Gleaton said, is contributing to physician burnout.

Medical students are not taught about handling finances or running a practice, she said.

“You’re not taught that part because you’re supposed to follow what’s best for each individual patient. So that leads to a whole bunch of decisions when you’re out in the real world that really make a lot of unhappiness between the patients and the institution and the goal of trying to get the best care for the patient.”

“It’s getting to be slowly but surely increasingly difficult, I think, for everybody in the healthcare system,” she said.

While the administrative burden on physicians is heavy, “sometimes we don’t even get to see the patients that we would like to take care of but they can’t get access to the office because they just don’t have insurance,” Dr. Paul Cain, an Auburn orthopedist and MMA president said.

A year ago, Gov. Janet Mills’ office said that Maine’s uninsured rate dropped from 8% in 2019 to 5.7% in 2021 through a combination of employer-based coverage and MaineCare. Mills said the drop represented “the largest percentage decline among all states in the nation.”

As of May, 360,187 Mainers were enrolled in MaineCare, the state’s Medicaid program, according to data from the U.S. Centers for Medicare and Medicaid. About a third were able to enroll through MaineCare expansion, according to the Maine Department of Health and Human Services.

Still, complaints about uneven access, long wait times for appointments, and high out of pocket costs are still common.

Only four other states’ medical associations — Hawaii, New Hampshire, Vermont and Washington — have passed similar resolutions, according to Physicians for a National Health Program and Maine AllCare, which call for publicly funded healthcare coverage.

The American Medical Association has not passed a resolution or adopted a statement similar to Maine’s or the other states. Its House of Delegates — made up of representatives of all fifty states’ medical associations — came within 30 votes of endorsing Medicare for all in 2020, Steele said.

“While we are among a small number of medical associations to do this, we think our actions represent a growing consensus of physicians, both in Maine and nationally, that it’s time for every American to have healthcare insurance and to figure out how to do that in a way that’s affordable and equitable,” he said.

Correct income inequality among doctors

By George Bohmfalk, M.D.
The Washington Post, Letters, September 8, 2023

Elisabeth Rosenthal’s Sept. 6 op-ed, “A disappearing species in America: The family doctor,” described many reasons more family practice and other primary-care physicians don’t enter or remain in those practices. The major one that is most fixable is their low incomes.

In 2017, family-practice physicians in their peak years earned an average of $230,000. Neurosurgeons took home $920,000. Very few argue for equal pay for all physicians, but not even I, a retired neurosurgeon, can justify one specialty being worth four times another. Most physicians enter medicine to help people, not drive them into bankruptcy and amass unanticipated and unneeded wealth. Very few high-earning specialists will voluntarily lower their fees. As with Medicare’s new power to negotiate drug prices, only a federal program such as Medicare-for-all could correct these extreme income inequities and return control of their practices to physicians from their corporate owners.

Neurosurgeons and orthopedic surgeons can certainly support their families on a little less so that we all might benefit from more primary-care physicians.

https://www.washingtonpost.com…